Public Health England, Health Trainers and Health Inequalities
Recently I was lucky enough to speak at the the annual Health Trainer conference organised by the Royal Society of Public Health. All credit to the RSPH who have been steadfast in their support for this service, building on the early work from Leeds Beckett University – in particular my colleague Judy White.
Around since 2004
Health Trainers have had remarkable staying power – here is a bit of history from the Health Trainers England website:
The role of health trainer was first outlined in the 2004 White paper Choosing Health. Since their inception they have generated a great deal of interest from commissioners, provider services and the public. From the start they were intended to offer support from next door rather than advice from on high and their aim was to:
- Target ‘hard to reach’ and disadvantaged groups
- Increase healthy behaviour and uptake of preventative serviceProvide opportunities for people from disadvantaged backgrounds to gain skills and employment
- Reduce health inequalities
The different approach taken by two of the key speakers at the conference unintentionally highlighted some of the tensions that exist with regard to Health Trainers. This tension is set out in a good report (Indicators of Change – the adaptation of the health trainer service in England) produced by Emma Lloyd the Policy and Research Executive for the RSPH
In the paper Emma notes that:
“There is a growing polarisation of services, between on the one hand services adopting more clinical work and on the other services consciously resisting this move and instead, placing a far greater focus on the wider determinants of health and community development”
If I understood him correctly his presentation focussed on the way in which the evidence base has developed – and the opportunities that are presented by bringing ‘behavioural insight theory’ which is to some significant degree informed by the work of the Behavioural Insights Team – formerly the Cabinet Office Nudge Unit.
The presentation dispirited me – it highlighted the disconnect between Public Health England and the experience of citizens – particularly the most disadvantaged. There was no mention of health inequalities at all and little understanding shown about the connections that exist between poor mental health and vulnerability. Instead we had the usual rather technocratic sets of interventions targeted at particular behaviours (smoking) or conditions (obesity). It felt as though Public Health England are trying to shoehorn Health Trainers into an older clinical model of behaviour change – the person as a collection of conditions.
The second presentation was completely different. It was by Sam German – who is supporting an initiative called called The Healthy Villages Partnership. He told us stories of connection and relationships. For example a story of an elderly woman who was isolated and depressed following the death of her husband and how a community health worker helped her reconnect with one of her passions – dancing – and the difference this made to her health and wellbeing.
The key for me was that people – their circumstances, histories AND skills and hopes were at the centre of Sam’s narrative.
I find this dissonance between these two views quite shocking. One is about ‘the other’ as though we are a just a collection of behaviours to be triggered and the other is about seeing us as human beings who want to be creative, who want to give and whose circumstances are one of the things we have to recognise and address if we are to be fulfilled.
Coincidentally at around the same time as this conference Citizens Advice produced a report in association with the Behavioural Insights Team called “Applying behavioural Insights to regulated markets” which looks at how behaviour change theory can help people take control as consumers of financial and utility services. Unlike the Public Health England presentation it does recognise the impact of inequality and vulnerability on our ability to change our behaviour and take control.
What needs to happen.
- Public Health England need to change their paradigm. At the moment they produce too much material that feels disconnected from the lived experience of people – they urgently need to develop a whole person narrative rather than a condition focussed one.
- PHE must raise their game with regard to the science – it is frankly embarrassing when a charity can produce a more coherent narrative on behaviour change than the governments leading Public Health agency.
- We urgently need an assertive position on the person centred role of health trainers, health champions or community health workers that affirms the importance of this approach to counterbalance the a-contextual science of the Public Health England model.
What do you think?